Integrated care means integrating the best care

Lately, it seems that there has been a lot of chatter regarding the concept of integrated care (I will use the abbreviation IC because it makes it sound mysterious and highbrow). The Rhode Island Primary Care Physicians Corporation (RIPCPCIC) defines IC as “aligning one cohort of physicians that all work collaboratively to provide the best patient care, often using the same medical record system and having the same goals in mind.”

In fact, this seamless patient care should not have to be defined-it should be an unwritten code when working with our patients. However, this was not always representative of IC when defined by ophthalmology. Sadly, I think there is still thin layer of skepticism on both sides.

No longer us vs. them

Historically, optometry and ophthalmology have worked in parallel universes with very little room to cross paths. Yet, this model didn’t provide the appropriate care necessary for our aging populace.

Organizations such as American Society of Cataract and Refractive Surgeons (ASCRS) and American Academy of Ophthalmology (AAO) were able to view optometry as adjunctive or at least a primary source of ophthalmic care for patients. Regarded in this manner, optometrists regularly attended meetings and shared podiums with their ophthalmology brethren.

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Sometime not that long ago, this peaceful commune of eyecare professionals was fractured by the acceptance of optometric diagnostic and therapeutic expansion. In fact, we were disinvited from the educational party-I mean not even a seat at the technician table! Forget the whole concept of comanagement, this was drawing a line in the sand and staking claim.

Frankly, it hurt. It hurt optometry. It hurt a lot of non-agreeing ophthalmologists, and most of all, it detracted from the common goal of integrating our care for the patients we share and thus hurt the patient.

A lot has changed in the decade since that day the proverbial music died. Refractive-minded optometrists got together to create a forum of research and education in the surgical arena.

Pioneers such Paul Karpecki, OD, and Lou Phillips, OD, started the Optometric Council on Refractive Technology (OCRT) and created optometry’s own small yet effective forum to cooperatively work with ophthalmologist to keep this flow of information downstream.

OCRT was joined by other integrated societies, such as Optometric Glaucoma Society (OGS) and Optometric Retina Society (ORS) to further establish the role that optometrists play in the management of these surgical and disease states. Integrating new technology, new ideas, and sea changes into our treatment theme has provided our patients with better eye care.

The formation of surgical-related optometry-centric meetings filled a void and at the same time strengthened the acumen of all optometry. Awareness was raised that it is not us vs. them; instead it is we for patients, leading to more discussion about what constitutes an IC.

Next: Coordinated care means communication

Coordinated care means communication

Coordinated care for our patients is a necessity to achieve the best results for our patients. A great example of that is the discussion around ocular surface disease (OSD) and surgical outcomes. In fact, no one can argue that this correlation of confounding results from OSD begins much earlier than the need for surgery or the desire to have elective surgery.

The fact that the contact lens dropout rate has not changed in some time and is predicated by patient discomfort is an alarm that is on full blast. The use of point of service technology, such as TearLab or RPS, and the integration of meibography and tear evaluation is becoming a common practice in OD and MD practices alike.

These diagnostic tests should not be reserved for one specialty-much like the measurement of hysteresis for glaucoma, they are integrated into patient care. These results and ultimate treatment strategies, to achieve the best surgical outcomes, should be the cornerstone of surgical IC.

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The model created by the doctors in Rhode Island is an integration of education, mutual respect, and most importantly putting patients’ needs front and center.

Unfortunately, there is still a small populace that believes that IC is intended to be a way to employ optometry or receive referrals-essentially glorified technicians who are not given the opportunity to fully use their licensed skills. While surgeons are busier in the surgical suite, ODs can be managing the disease state, pre and post surgical, as well as performing some laser treatments.

Optometry, for its part, is also skeptical of past relationships tarnishing a new working relationship. Working in a co-op or IPA as established in Rhode Island diminishes some of the independence that we as clinicians maintain, and change is scary. Letting go of some of our demons will allow our profession to visualize the current environment that newer ophthalmologist may have toward IC.

The natural selective process is the gatekeeper that will determine how IC is going to be perceived and implemented. In a pure Darwinian model, the practices that realize that patients benefit when an OD and MD work in harmony will ultimately survive.

ODs should seek out MDs who share a common goal, use the latest technology, discuss what your role will be in the surgical process (both pre and post), and establish a line of communication.

MDs need to allow us to diagnose the disease and treat to our fullest capabilities, communicate surgical processes, and respect the relationship we all have with the patient.

As we move into the digital era, there is no reason ODs and MDs should not continue to interface in real time for the best IC. We should embrace and welcome an era of true IC.

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